Healthcare Provider Details

I. General information

NPI: 1073699120
Provider Name (Legal Business Name): EDYTHE B. PARK M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/31/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2725 SE MARICAMP RD
OCALA FL
34471-5537
US

IV. Provider business mailing address

2725 S.E. MARICAMP ROAD
OCALA FL
34471
US

V. Phone/Fax

Practice location:
  • Phone: 352-369-8700
  • Fax: 352-369-8703
Mailing address:
  • Phone: 352-369-8700
  • Fax: 352-369-8703

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME100186
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: